What’s New in the 2020 European Recommendations on Atrial Fibrillation?

Epidemiology
AF is a burden that is estimated to affect between two and four percent of the adult population These numbers are constantly increasing all around the world, which poses a growing problem for health systems.
As an example, in Europe, it’s estimated that a 55-year-old individual has a one-in-three chance of experiencing AF over the course of their lifetime.

4S Scheme
The new guidelines recommend using the 4S scheme to characterize AF.
- The first S is stroke risk, evaluated by the CHA2DS2-VASc score
- The second S is symptom severity, evaluated by the EHRA score
- The third S is severity of AF burden
- The fourth S is substrate severity

The importance of screening
Many factors explain the importance of screening for AF in the general population. These include the high frequency of asymptomatic and minimally symptomatic forms and the possibility of avoiding the risk of a stroke if AF is detected.
It’s now a Class I recommendation that AF screening be conducted for everyone over the age of 65. This mass screening can be done by taking the pulse or by using an ECG device. There are many devices available for ECG screening to detect AF (see figure below). Smartphone apps and smartwatches are the most commonly used.

Treatment: ABC
The acronym ABC now summarizes three main AF treatment principles that have been streamlined.
A for Anticoagulation. No major new guidelines in this section. Anticoagulation is recommended for the vast majority of AF patients, with the decision made based on the CHA2DS2-VASc score. In this situation, direct oral anticoagulants are used rather than VKAs except in some cases (mechanical valves, mitral stenosis).
B for Better symptom control. The treatment strategy chosen is largely guided by the patient’s symptoms, therefore they must be precisely evaluated. The patient is truly centered in the care pathway. AF ablation is now used more often (higher recommendation class) either after medication failure or as a first line treatment in certain cases. The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial 4 (EAST-AFNET 4), presented in Hotline and published in the New England Journal of Medicine, shows the superiority of an early rhythm-control strategy.
C for Comorbid conditions management The guidelines highlight the importance of lifestyle and the necessity of controlling sleep apnea, obesity, high blood pressure and, in general, all factors that contribute to AF.

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